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Inspection Report Number <br /> Waste Tire Survey & Inspection Repo. <br /> 111 State of California <br /> CIWMB181(New 04/04) Survey Form - Page 1 T i 1 _ 1088324 O Q 8 8 Q <br /> 1 9 <br /> California Integrated Waste Management Board <br /> A-Survey _ BLUE OR BLACK INK PEN <br /> -t <br /> iness Profile Inspection Details <br /> TPID- 'J i Inspection Type (Fill one) <br /> Site Suffix: 3 � l 4-r l ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: /^��c��l.n ( 0,10, O CHP O CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name !! Inspected By Inspector <br /> �5fSL <br /> Physical Address Ci 1 v l w /47ct nl la;1 et <br /> _ Inspection Date 5 f <br /> r�(Ack (6,m r CA q"�j)01 Time In Time Out l <br /> Business Rep Title J p 0 AM 0 AM <br /> .,1 JL O PM If"" O PM <br /> note- 1 61+z ke I t COQ� �'�nCC 1��• Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O 16 Closed Q Altered NIA A11A- <br /> GPS Latitude 1-�/f} Q Hauler O Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — 0 Planned Q OTR Q End-Use Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> J Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O Service Station Q Hauler Q Agriculture Q Shredder ® Others <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> [V I A ,HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> O O <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities - <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators *In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> e � <br /> inspection Form Included: Q + <br /> Comments Included: � �� <br /> Business Rep's Signature Phone Number p to' i nature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � � C f ` L 1 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />